Client Background Form

New Patient Details

New Client's Name

New Client's Surname

Is the client under 18 years of age?

Yes

Parent/Guardian Name

Client's Date of Birth

Client's Contact Number

Client's Address

Street Address

City

State

Postcode

Do you have any cultural or spiritual needs or requirements we should know about?

Yes

Please tell us what cultural or spiritual needs or requirements we should know about

Are you of Aboriginal and/or Torres Strait Islander origin?

Yes

Do you require an interpreter?

Yes

What language do you require an interpreter for?

Is there a behaviour support plan in place or any behavioural difficulties that we should know about?

Yes

Please tell us more about the behaviour support plan or behavioural difficulties

Select the area that MouthWorks will be helping you with

Speech Therapy

Occupational Therapy

Physiotherapy

Psychology

Dietetics

Music Therapy

Speech Therapy

This information will help us prepare for your first appointment with Mouthworks.

Is there a family history of speech, language or fluency(stuttering) difficulties?

Yes

Please provide a brief description of any family history of speech difficulties.

Are you currently seeing any other health/educational professionals? These can include Occupational Theapists, Psychologists, Paediatricians, TAS DAS, Speech Pathologists etc.

Yes

Is currently seeing any other health/educational professionals? These can include Occupational Theapists, Psychologists, Paediatricians, TAS DAS, Speech Pathologists etc.

Yes

Please list the other health/education professionals that are currently being seen.

Have you ever had a hearing test?

Yes

Has had a hearing test?

Yes

What was the outcome of the hearing test?

Does have any trouble with eating, drinking or swallowing?

Yes

Do you have any trouble with eating, drinking or swallowing?

Yes

Please describe any issues with eating, drinking or swallowing

Does take any medications or supplements?

Yes

Do you take any medications or supplements?

Yes

Please list any supplements or medications that are currently being taken.

Occupational Therapy

Please list any diagnosis given by other health care professionals.

Is currently taking any medications?

Yes

Are you currently taking any medications or supplements?

Yes

Please list any supplements or medications that are currently being taken.

Have you had any significant adverse experiences? These can include hospitalisations, bullying, trauma etc.

Yes

Has had any significant adverse experiences? These can include hospitalisations, bullying, trauma etc.

Yes

Please describe the adverse experiences here:

Other Health Care Professionals currently involved in your care? Tick all that apply

Psychologist

Physiotherapist

Speech Pathologist

Dietitian

Paediatrician

Other

None

Other Health Care Professionals currently involved in 's care? Tick all that apply

Psychologist

Physiotherapist

Speech Pathologist

Dietitian

Paediatrician

Other

None

Please list any other Health Care Professionals currently involved.

Physiotherapy

What are your areas of concern?

Any relevant medical conditions?

Other Health Care Professionals currently involved in your care? Tick all that apply

Psychologist

Speech Pathologist

Dietitian

Paediatrician

Occupational Therapist

Other

None

Other Health Care Professionals currently involved in 's care? Tick all that apply

Psychologist

Speech Pathologist

Dietitian

Paediatrician

Occupational Therapist

Other

None

Please list any other Health Care Professionals currently involved.

Psychology

Why are you coming to see us?

Are you currently taking any medications or supplements?

Yes

Please list any medication and/or supplements you are currently taking?

Other Health Care Professionals currently involved in your care? Tick all that apply

Physiotherapist

Speech Pathologist

Dietitian

Paediatrician

Occupational Therapist

Other

None

Other Health Care Professionals currently involved in 's care? Tick all that apply

Physiotherapist

Speech Pathologist

Dietitian

Paediatrician

Occupational Therapist

Other

None

Please list any other Health Care Professionals currently involved.

Dietetics

Why are you coming coming to see us?

Why is coming coming to see us?

I can bring my recent blood test results to my appointment.

Yes

I can bring 's recent blood test results to my appointment.

Yes

What is your weight history?

What is 's weight history?

Does take any medications or supplements?

Yes

Do you take any medications or supplements?

Yes

Please list any supplements or medications that are currently being taken.

Please list any relevant medical conditions.

Is there a family history of any significant medical issues? For example: Diabetes, Heart Disease, Cancer, Food Allergies etc.

Yes

Please describe your family medical history.

Do you ever experience...(tick all that apply)

Reflux

Nausea

Constipation

Diarrhoea

Does ever experience... (tick all that apply)

Reflux

Nausea

Constipation

Diarrhoea

How would you describe your appetite?

How would you describe 's appetite?

Music Therapy

Where did you hear about Music Therapy?

What do you most want your child to gain from attending music therapy? Tick all that apply.

Improved communication skills

Improved social skills

Confidence

Reduced anxiety

Emotional regulation

Improved attention span and focus

Improved impulse control

Improved motor skills

Academic goals

Please list any other goals that you want to achieve through music therapy.

Does your child have any particular song preferences?

Yes

Please list your child's song preferences here:

Have you noticed that your child responds (positively or negatively) to different genres/types of music? E.g. loud, fast, rock, classical, etc?

Yes

Please describe the type of music your child responds to and how they respond.

Does your child play any instruments or enjoy experimenting with any instruments at home or in a class?

Yes

What instrument(s) does your child play/enjoy experimenting with?

What motivates your child or bings them joy?

Do you use any communication aids with your child? For example: visuals, schedules, AAC devices.

Yes

Please tell us about the communication aids you use with your child.

Are there any precautions we should take when working with your child? For example: Sensory triggers, aggressive behaviour etc.

Yes

Tell us about any precautions we should take when working with your child.

Extra Information & Consent

Please provide any reports, assessment, test results or any other documentation you have which may help us.

Choose File

Is there anything else that you feel might be helpful for us to know to prepare for your visit with MouthWorks?

I acknowledge that I am responsible for all fees and charges that I incur whilst receiving treatment at MouthWorks. I understand that all fees are payable on the day of consultation. I have read and agree to the Mouthworks Terms and Conditions and Privacy Policy

I acknowledge that I am responsible for all fees and charges that my child incurs whilst receiving treatment at MouthWorks. I understand that all fees are payable on the day of consultation. I have read and agree to the Mouthworks Terms and Conditions and Privacy Policy

Day	hours
Mon - Wed	8am - 6pm
Thur & Fri	8am - 5pm

Completing this form will provide us with all the details necessary to get started.

New Patient Details

Speech Therapy

Occupational Therapy

Physiotherapy

Psychology

Dietetics

Music Therapy

Extra Information & Consent